MED SURG HESI EXAM NEWEST ACTUAL EXAM
MED SURG HESI EXAM NEWEST ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) WITH RATIONALES |ALREADY GRADED A+||BRAND
NEW VERSION!!
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is
experiencing tumor lysis syndrome (TLS)?
Serum PTT of 10 seconds.
Serum calcium of 5 mg/dL. Correct
Oxygen saturation of 90%.
Hemoglobin of 10 g/dL.
Tumor lysis symdrome (TLS) results in hyperkalemia, hypocalcemia,
hyperuricemia, and hyperphosphatemia. A serum calcium level of 5, which is low,
is an indicator of possible tumor lysis syndrome.
Which intervention should the nurse plan to implement when caring for a client
who has just undergone a right above-the-knee amputation?
Maintain the residual limb on three pillows at all times. Incorrect
Place a large tourniquet at the client's bedside. Correct
Apply constant, direct pressure to the residual limb.
Do not allow the client to lie in the prone position.
A large tourniquet should be placed in plain sight at the client's bedside, in the
event severe bleeding occurs. The purpose is to have the tourniquet available to
apply to the residual limb to control bleeding if hemorrhaging was to occur.
1|Page
, MED SURG HESI EXAM NEWEST ACTUAL EXAM
Which nail color alteration should the nurse expect to observe in a client with
chronic kidney disease?
Horizontal white banding. Correct
Diffuse blue discoloration.
Diffuse brown discoloration.
Thin, dark red vertical lines.
Fingernails and toenails can be affected by chronic kidney disease. This condition
may cause horizontal white lines or bands (leukonychia) to appear on the nails.
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD). Which information should
the nurse include?
Limit dietary selection of cholesterol to 300 mg per day.
Increase intake of soluble fiber to 10 to 25 grams per day. Correct
Decrease plant stanols and sterols to less than 2 grams/day.
Ensure saturated fat is less than 30% of total caloric intake.
To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber should be increased to between 10 and 25 grams per day. According
to the American Heart Association, soluble fibers helps reduce LDL cholesterol
levels.
Tenesmus
a continual or recurrent inclination to evacuate the bowels, caused by disorder of
the rectum or other illness.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which assessment finding should the nurse expect this client to exhibit?
2|Page
, MED SURG HESI EXAM NEWEST ACTUAL EXAM
Lower left quadrant pain and a low-grade fever. Correct
Severe pain at McBurney's point and nausea.
Abdominal pain and intermittent tenesmus.
Exacerbations of severe diarrhea.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is
the most common area for diverticula, and the inflammation of diverticula causes
a low-grade fever.
Which finding should the nurse identify as most significant for a client diagnosed
with polycystic kidney disease (PKD)?
Hematuria.
2 pounds weight gain.
3+ bacteria in urine. Correct
Steady, dull flank pain.
Urinary tract infections (UTI) for a client with polycystic kidney disease (PKD)
require prompt antibiotic therapy to prevent renal damage and scarring which
may cause further progression of the disease so bacteria in the urine would be
significant finding.
A client has been hospitalized with a femur fracture and is being treated with
traction. Which action by the nurse is the priority when caring for this client?
Assess neurovascular status. Correct
Change the client's position.
Inspect the traction equipment.
Review pain medication orders.
3|Page
, MED SURG HESI EXAM NEWEST ACTUAL EXAM
The use of traction for long bone fractures reduces the potential for damage to
the surrounding tissues. Reports of increased pain may indicate circulatory
compromise or tissue damage (compartment syndrome). Assessing the client's
neurovascular status is the nurse's highest priority.
A client is placed on a mechanical ventilator following a cerebral hemorrhage,
and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the
priority nursing diagnosis for this client?
Impaired communication related to paralysis of skeletal muscles. Correct
High risk for infection related to increased intracranial pressure.
Potential for injury related to impaired lung expansion.
Social isolation related to inability to communicate.
To increase the client's tolerance of endotracheal intubation and/or mechanical
ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed.
Impaired communication is a serious outcome because the client cannot
communicate his/her needs due to intubation and diaphragmatic paralysis caused
by the drug.
An elderly client is admitted with a diagnosis of bacterial pneumonia. When
observing the client for the first signs of decreasing oxygenation, the nurse
should assess for which clinical cues?
Abominal distention.
Undue fatigue.
Cyanosis of the lips.
Confusion and tachycardia. Correct
The onset of pneumonia in the elderly may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate due to the decreased
4|Page
MED SURG HESI EXAM NEWEST ACTUAL EXAM COMPLETE 100
QUESTIONS AND CORRECT DETAILED ANSWERS (VERIFIED
ANSWERS) WITH RATIONALES |ALREADY GRADED A+||BRAND
NEW VERSION!!
The nurse is assessing a client's laboratory values following administration of
chemotherapy. Which lab value leads the nurse to suspect that the client is
experiencing tumor lysis syndrome (TLS)?
Serum PTT of 10 seconds.
Serum calcium of 5 mg/dL. Correct
Oxygen saturation of 90%.
Hemoglobin of 10 g/dL.
Tumor lysis symdrome (TLS) results in hyperkalemia, hypocalcemia,
hyperuricemia, and hyperphosphatemia. A serum calcium level of 5, which is low,
is an indicator of possible tumor lysis syndrome.
Which intervention should the nurse plan to implement when caring for a client
who has just undergone a right above-the-knee amputation?
Maintain the residual limb on three pillows at all times. Incorrect
Place a large tourniquet at the client's bedside. Correct
Apply constant, direct pressure to the residual limb.
Do not allow the client to lie in the prone position.
A large tourniquet should be placed in plain sight at the client's bedside, in the
event severe bleeding occurs. The purpose is to have the tourniquet available to
apply to the residual limb to control bleeding if hemorrhaging was to occur.
1|Page
, MED SURG HESI EXAM NEWEST ACTUAL EXAM
Which nail color alteration should the nurse expect to observe in a client with
chronic kidney disease?
Horizontal white banding. Correct
Diffuse blue discoloration.
Diffuse brown discoloration.
Thin, dark red vertical lines.
Fingernails and toenails can be affected by chronic kidney disease. This condition
may cause horizontal white lines or bands (leukonychia) to appear on the nails.
The nurse is providing dietary instructions to a 68-year-old client who is at high
risk for development of coronary heart disease (CHD). Which information should
the nurse include?
Limit dietary selection of cholesterol to 300 mg per day.
Increase intake of soluble fiber to 10 to 25 grams per day. Correct
Decrease plant stanols and sterols to less than 2 grams/day.
Ensure saturated fat is less than 30% of total caloric intake.
To reduce risk factors associated with coronary heart disease, the daily intake of
soluble fiber should be increased to between 10 and 25 grams per day. According
to the American Heart Association, soluble fibers helps reduce LDL cholesterol
levels.
Tenesmus
a continual or recurrent inclination to evacuate the bowels, caused by disorder of
the rectum or other illness.
A client is admitted to the hospital with a diagnosis of severe acute diverticulitis.
Which assessment finding should the nurse expect this client to exhibit?
2|Page
, MED SURG HESI EXAM NEWEST ACTUAL EXAM
Lower left quadrant pain and a low-grade fever. Correct
Severe pain at McBurney's point and nausea.
Abdominal pain and intermittent tenesmus.
Exacerbations of severe diarrhea.
Left lower quadrant pain occurs with diverticulitis because the sigmoid colon is
the most common area for diverticula, and the inflammation of diverticula causes
a low-grade fever.
Which finding should the nurse identify as most significant for a client diagnosed
with polycystic kidney disease (PKD)?
Hematuria.
2 pounds weight gain.
3+ bacteria in urine. Correct
Steady, dull flank pain.
Urinary tract infections (UTI) for a client with polycystic kidney disease (PKD)
require prompt antibiotic therapy to prevent renal damage and scarring which
may cause further progression of the disease so bacteria in the urine would be
significant finding.
A client has been hospitalized with a femur fracture and is being treated with
traction. Which action by the nurse is the priority when caring for this client?
Assess neurovascular status. Correct
Change the client's position.
Inspect the traction equipment.
Review pain medication orders.
3|Page
, MED SURG HESI EXAM NEWEST ACTUAL EXAM
The use of traction for long bone fractures reduces the potential for damage to
the surrounding tissues. Reports of increased pain may indicate circulatory
compromise or tissue damage (compartment syndrome). Assessing the client's
neurovascular status is the nurse's highest priority.
A client is placed on a mechanical ventilator following a cerebral hemorrhage,
and vecuronium bromide 0.04 mg/kg q12 hours IV is prescribed. Which is the
priority nursing diagnosis for this client?
Impaired communication related to paralysis of skeletal muscles. Correct
High risk for infection related to increased intracranial pressure.
Potential for injury related to impaired lung expansion.
Social isolation related to inability to communicate.
To increase the client's tolerance of endotracheal intubation and/or mechanical
ventilation, a skeletal-muscle relaxant, such as vecuronium, is usually prescribed.
Impaired communication is a serious outcome because the client cannot
communicate his/her needs due to intubation and diaphragmatic paralysis caused
by the drug.
An elderly client is admitted with a diagnosis of bacterial pneumonia. When
observing the client for the first signs of decreasing oxygenation, the nurse
should assess for which clinical cues?
Abominal distention.
Undue fatigue.
Cyanosis of the lips.
Confusion and tachycardia. Correct
The onset of pneumonia in the elderly may be signaled by general deterioration,
confusion, increased heart rate or increased respiratory rate due to the decreased
4|Page
